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This is the second of two posts prompted by Dr. Robert Centor’s critique of a recent New York Times Magazine article accusing America of “stealing [sic] the world’s doctors.” In the first post, I show how US immigration policy for physicians is a boondoggle of near-comedic proportions that doesn’t even constitute an effort at “theft,” given that it’s hard-pressed to hold onto me after I graduate (as I explain, I should be one of the easier doctors to “steal”).

Now let’s look at the counterfactual situation. Suppose the it were actually easy and straightforward for physicians to immigrate to the US (or to remain, in my case), gain licensure, and be certified in their specialties. Suppose the immigration and licensure systems were designed with this very goal in mind. Would this be a bad thing?

The conventional wisdom is that the emigration of skilled professionals from less to more-developed countries is bad for the less-developed countries: this process is often referred to as “brain drain.” Critics argue that “brain drain” harms poorer countries by preventing the development of local talent, skills, and professionals that are often sorely needed. They also point to the fact that many countries subsidize education at least to some extent, only to see the investment in their citizens’ human capital slip away beyond their shores.

Yet even this analysis misses the fundamental point. To insist, as the New York Times does, that foreign physicians somehow “belong” to their home countries is to objectify and commodify them. When you think about it, it’s a remarkable assumption for anyone to make. Foreigners are people too. We’re not chess pieces to be pushed around a board, traded for promises of foreign aid, trade preferences, or anything else one might imagine. The Canadian government has no more claim on me and my career than the American government does on anyone who has ever attended a public school in this country.

This is a universal principle. I don’t care how poor the country is, no government can claim to “own” its people in this way. It’s absurd to suggest that the United States government should alter its immigration policy to cater to other countries’ desire to engage in this form of subtle repression, and even more absurd to think that this would actually benefit anyone.

Physicians who voluntarily leave one country for another in the hopes of making a better life are not “being stolen.” Not unless you think they’re owned by someone other than themselves. At its core, that’s what this discussion is all about. And that’s why, in my mind, there should be no ambiguity as to the right conclusion.

As a student at an LCME-accredited American medical school, I don’t fall into the “international medical graduate” (IMG) category in quite the same way as those in the article. And despite the fact that I’m “only” Canadian, I’m still foreign enough to have to figure out where my next visa will come from for residency, fellowship, and beyond. This post will not be an extended disquisition on the finer points of American immigration law and visa classifications (subjects with which I am far too familiar). You will, however, get a taste of how dysfunctional the American approach to foreign physicians is, especially at a time marked by widespread predictions of an impending doctor shortage.

Most public medical schools in the US and many private schools will not even consider non-citizen/non-permanent resident (foreign) applicants. Those of us who do get an offer somewhere find that we are not eligible for US government financial aid, and for a great deal of school-based aid as well. Despite this, we still benefit indirectly from taxpayer subsidies. Tuition makes up a minuscule fraction of medical school revenue; according to SUMS‘s tax returns, our tuition barely covers the costs of the medical education and educational technology support staff. Nothing more. The rest comes from patient care revenues and various grants, much of which in turn comes from the taxpayer.

After receiving a medical education at great personal financial cost (debt), yet one that’s also heavily subsidized by the US taxpayer, the expectation is that we go home. Or at least leave the country. Completing post-graduate training in the US requires finding residency programs that are willing to sponsor one of the two main types of visas that can be used for this purpose: the J-1 comes with a 95% iron-clad requirement to leave the US and work in one’s home country for two years upon completion of training before one can come back to this country; the H-1B comes with a 100% iron-clad time limit of six years (for reference, here is a list of residency length by field, not including sub-specialty fellowships). Even assuming one could find and be accepted into a program that will sponsor either visa, neither seems particularly conducive to “theft” of foreign physicians.

Unlike in medical school, foreigners in US residencies and fellowships often do benefit from direct US taxpayer subsidy, as Medicare pays for most residency positions, including salary and benefits. So what happens to foreigners who receive direct government subsidies to train in their specialty?

Again, the expectation is that we will go home (in the case of the J-1 visa), or at least leave the country (in the case of the H-1B). The United States is one of the few, perhaps the only, developed country that requires all long-term immigrants to be sponsored by an employer or a family member. There is no “points” system for independent applicants; no way for someone like me to prove that I’m smart, talented, possess in-demand skills, and probably ought to be allowed to stay indefinitely (not to mention the hundreds of thousands of dollars of subsidy I will have enjoyed by this point). More shockingly, there’s seemingly no desire on the part of the US government to hold on to the medical talent that it paid to develop.

What employer would sponsor a foreign physician? Moreover, what employer would sponsor any employee for permanent residence before at least a few years of full-time employment have passed? The H-1B comes with a six-year time limit; look at the length of various residencies at the link above. We’re short primary care physicians (3 years), yes, but we’ll be short general surgeons (5 years) and cardiologists (6 years) as well.

If the United States is “stealing” [sic] foreign physicians, it’s one of the most tragically/comically inept thieves I’ve heard of. Even in my “easy” case, after I will have spent 7+ years being educated at world-class American schools (11+ if you count college), the US is happy and indeed seemingly eager to see me go.

Some people would approach this conundrum entirely differently. They would argue that because foreigners in the American medical training process receive indirect and then direct government subsidies, the process should be closed to them in the first place. I understand the logic, but this strikes me as doubling-down on the foolishness of the current system. Getting into medical school and residency is frighteningly competitive. Being a foreigner only makes it harder. I make no claims as to myself, but one would therefore expect the marginal foreign applicant to be at least as good as the marginal American applicant… if not better. That some of them manage to stay in the US to practice medicine even in spite of the numerous hurdles along the way should suggest even more strongly that these are the people you want to hold on to.

What with this whole commencement of medical school, it’s been a while since the last edition. So I bring you slightly more than usual

Fun tidbits, health-related and otherwise, from around the ‘tubes:

Worthwhile Canadian Initiative reminds us that counterintuitive though it may be, there is an optimal amount of forgetting. Dr. Bob Centor suggests that proposed performance payment for physicians forgets the role of patient preferences in steering therapy. Sticking with patient preferences, twoposts at KevinMD argue that the long-term viability and feasibility of the PCMH care model should be determined by patient desires. That is, if the PCMH model is workable to begin with… an arguable proposition. Of course, if recent trends with retail clinics are any indicator… well, it could indicate many things. You be the judge.

End-of-life spending has gotten some attention. The DMCB and Health Affairs alike aren’t convinced that reducing this spending will be easy, or that the savings are in fact possible to realize, at least as conventionally measure. Relatedly, a guest poster at KevinMD points out that in medicine, sometimes “more is more.” Not all potential cost-savings are “free lunches.”

Rounding out this week’s edition… Medical schools, broadly speaking, do three things. They educate physicians, produce research, and care for patients. As someone just starting medical school, it’s nice to read things like this post from Dr. Centor arguing that the primary mission of medical schools should in fact be medical education.

Going back to the subject of Congressional hearings, two bloggers at the Economist explain why Goldman Sachs and the financial services industry generally aren’t as evil as people seem to want them to be.

There’s been a lot of talk about reforming physician pay and medical organization, but not a lot of emphasis on new and innovative models of health insurance provision. (As I discuss in this post, the PPACA will probably do more to ossify the present state of health insurance than anything else) That’s why this post from the Health Business Blog, highlighting a value-based, market-oriented, real insurance offering in Fresno, CA is so heartening.

WhiteCoat brings us the story of a case in which a physician was sued, and settled, for malpractice. It sounds pretty vanilla until you read that the physician was out of the country at the time the alleged malpractice was committed by a supervisee midwife who failed to contact the physician covering for the one who got sued. Malpractice affects physician behaviour through fear more than it does through changing actual risk. With stories like these, is it any wonder that the fear is still there? Also on the subject of lawsuits is this post by Amy Tuteur that suggests liability concerns as a major driver of increases in C-section rates.

Scott Greenfield at Simple Justice is probably my favourite lawyer I’ve never met. Two of his posts from this past month, takentogether, explain the reasons for my own discomfort with the way the victims’ rights movement is playing out in the US and Canada.

Jason Shafrin at Healthcare Economist has made some pretty pie charts detailing the breakdown of Medicare and Medicaid expenditures on categories such as physicians, hospitals, drugs, etc. While I knew intuitively that physicians constitute a small piece of the pie, it was still surprising to see it represented visually. It also suggests a way to win over skeptics of various payment reforms: if, as it seems, much of the cost of certain types of physician care is incurred downstream (as opposed to fees paid to the physician), then payment reform that seeks to lower overall costs by changing incentives should also be able to guarantee higher income for those types of physicians. Call it gainsharing, maybe?

You’ll also notice that A Cartoon Guide to Becoming a Doctor has been added to my blogroll and to the links on the sidebar. If you’re looking for more visual stimulation from your medblog collection, that’s a fantastic place to get it!

Fun tidbits, health-related and otherwise, from around the ‘tubes:

A letter to the editor of The Economist tells that “[t]he so-called precautionary principle is, in the words of risk-expert Bill Durodié, “an invitation to those without evidence, expertise or authority, to shape and influence political debates. It achieves that by introducing supposedly ethical or environmental elements into the process of scientific, corporate and governmental decision-making.”

Bob Centor points out that increasing medical school enrollment won’t be enough to solve projected future shortages of physicians, especially in primary care. He looks at increasing the number of primary care residency slots and improving pay for primary care physicians and residents. I would argue that this might not even go far enough: if the slots are there, who’s to say they’ll be taken unless the job gets much better than it is now?

Eugene Volokh tells of litigation that arose after an accident victim was mistaken as dead many, many, many times. I’m not one to second-guess decisions made under tricky circumstances (well, maybe I am), and I’m all for reducing “unnecessary medical tests” (whatever those are), but can it really hurt to double-check the pulse?

An alternate take on schizophrenia from a behaviourist perspective, entitled “Schizophrenia Is Not An Illness.” Provocative? To someone like me with only limited exposure to “traditional” approaches to mental illness, yes. The three-part series makes some interesting points and is well worth the read.

In 1964, President Lyndon Johnson placed an order for new pants. The tape and transcript of the phone call are … quite something. Be warned that LBJ uses graphic language to describe the desired specifications of the pants being ordered. He also belches without saying “excuse me,” and admits to carrying a knife to work.

A lot of health care revolves around providing reassurance and peace of mind (kinda like real insurance is supposed to, but that’s another topic for another day). Sometimes that’s for the patient’s benefit and sometimes for the physician’s. Oftentimes, it’s for both. Of course, peace of mind can be an expensive thing to come by. This story from ACP Internist illustrates this perfectly.

There exists a jurisdiction not too far from Florida that has recently imposed a health insurance mandate on some of the people present there. Those subject to the mandate who don’t already have insurance will have to buy a product that doesn’t cover pre-existing conditions and features payout caps. Guess where this is, I challenge you!

Don’t believe everything you read online, even from a somewhat-reputable source. This is especially true when it’s AOL recommending “medical tests that could save your life.” Or not.

Reason explains, in graphical form, a subject near and dear to my heart: US immigration law.